Ensuring Vitamin A Adequacy: Different Approaches Needed in Different Countries
The World Health Organisation has named vitamin A deficiency to be a public health problem in over half of all countries. Vitamin A is needed for vision, and also to prevent infections. Various public health measures are used around the world to help people with deficient diets to meet their vitamin A needs, such as food fortification, supplementation programs, improving dietary diversity and increasing the pro-vitamin A content of staples through bio-fortification. But there is no “one size fits all” measure to improve vitamin A status, as is shown via two articles published recently by Aguayo and co-workers on supplementation programs in Indian children, and Nel and colleagues on sources of vitamin A in South African communities.
The Aguayo article describes the success of India’s national vitamin A program in targeting Indian states with the highest burden of under-5 child mortality. The program involves a single high-dose vitamin A supplement being given first at 9 months of age together with the measles vaccination (100,000 IU), followed by further high-dose supplements (200,000 IU) given every 6 months until the age of 5. The authors report increases in program participation between 2006 and 2011, with the average percentage of children given at least one dose increasing from 60% to 92%, and the percentage of children receiving all doses increasing from 45% to 67%. The authors also found that the poorest households showed the largest increases in supplementation, and named the vitamin A supplementation program to be a “social equalizer”. Success factors in certain areas included strong leadership, good cooperation between government organizations responsible for delivering health care and development support, micro-planning, flexible dosing regimens, training and a stable supply chain.
The Nel publication on the other hand looked at vitamin A intakes in children aged 2 to 5 in the Hantam district of the Northern Cape Province in South Africa, an impoverished area where sheep farming is one of the main industries. Due to the study participants’ proximity to two sheep abattoirs, most households (90%) reported consuming sheep’s liver. Liver is an excellent source of many nutrients particularly vitamin A. On average, children obtained 537 RE vitamin A from liver, 80 RE from the national food fortification program, 122 RE from the national vitamin A supplementation, and the balance (200 RE) from the diet. Children of this age group require at least 200 RE per day, and the recommended safe intake is 400-450 RE per day, according to the FAO/WHO. The IOM has set an upper limit for safe long-term consumption at 600 RE for children aged 1 to 3, and 900 for children aged 4 to 8. The average vitamin A intake for this group was therefore at the upper limit for safe consumption. Interestingly, lower socio-economic households had a higher intake of liver, therefore their vitamin A consumption was higher. The study showed that poor vitamin A intakes and poverty are not necessarily associated with each other.
These studies highlight that nationwide “blanket” approaches to preventing nutrient deficiencies may not be the most effective approach. Nutritional deficiencies occur within individuals. While poverty and malnutrition are linked, local conditions and communities’ coping mechanisms can affect or even reverse the relationship. Nutrition interventions can also make good use of existing programs, such as vaccinations, to facilitate their dissemination. Successful programs depend on many seemingly unrelated factors working together. There is no “right” way to prevent malnutrition: a dynamic mix that is tailored as much as possible to the resources of those most in need is most effective.
Aguayo VM, Bhattacharjee S, Bhawani L, Badgaiyan N. India's vitamin A supplementation programme is reaching the most vulnerable districts but not all vulnerable children. New evidence from the seven states with the highest burden of mortality among under-5s. Public Health Nutrition 2014;FirstView:1-8. doi:10.1017/S136898001300342X
Nel J, van Stuijvenberg ME, Schoeman SE, Dhansay MA, Lombard CJ, du Plessis LM. Liver intake in 24–59-month-old children from an impoverished South African community provides enough vitamin A to meet requirements. Public Health Nutrition 2013;FirstView:1-8. doi:10.1017/S1368980013003212